![\"Accountable](\"http:\/\/intercase.org\/wp-content\/uploads\/2013\/03\/Accountable-Care-Process-flow-Plan-v011.png\")
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What is a “plan of care”?<\/strong><\/p>\n For the purposes of this discussion, a plan of care is any set of interventions that are scheduled for a patient.\u00a0 Interventions are generally divided into:<\/p>\n Development of a patient-specific plan of care<\/strong><\/p>\n There are many ways to describe the components of a plan of care, and many names to apply to each set of components.\u00a0 For the sake of this discussion, consider the following as a schematic of the process to create a plan of care:<\/p>\n We have two groups of interventions, one medical and one non-medical.\u00a0 When merged we have an “overall” plan of care.\u00a0 The overall plan would have the universe of medical interventions required to address the patient’s medical issues (either to diagnose or treat) and all of the\u00a0 non-medical activities required to enable the patient to comply with the medical plan<\/p>\n Now what?<\/strong><\/p>\n The art of care management is not in defining a plan of care.\u00a0 The art is in figuring out the “best” way to complete the plan (that is, to complete the interventions).\u00a0 In most contexts, the “best” approach is the least expensive avenue to complete the plan.\u00a0 The care team will usually opt for the least expensive approach for each intervention, or to substitute a single (expensive) intervention for a set of interventions that were inexpensive individually, but expensive in aggregate.<\/p>\n Often, the least expensive way to get interventions completed is to engage the patient and the patient’s family to assist.\u00a0 Clearly, the majority of medical interventions require a provider for delivery.\u00a0 But the majority of non-medical interventions do not require a provider, and can (and usually should) be leveraged onto the patient\/family.<\/p>\n The less expensive, the better<\/strong><\/p>\n If we can get the cost of managing a plan of care down, the result is that we can increase the number of patients<\/span> who are care management targets.\u00a0 If our only approach to care management is to assign a case manager to directly interact with patients, we are unlikely to get beyond the top 1.5% of patients with an active plan of care.\u00a0 On the other hand,\u00a0 if we can directly engage the patient and family to coordinate care, we are far more likely to be able to manage the 50% of dollars that are invested in the top 5% of patients.<\/p>\n Some quick arithmetic<\/strong><\/p>\n If a population incurs an average cost of $10,000 each (which is probably about right for 2014), the top 1.5% is likely to be incurring well over $200,000 each.\u00a0 The next 3.5%, however, are likely approaching about $50,000 each.\u00a0 We have a lot of options to deploy services in this first population where annual care costs are very high and an investment in care coordination of $5,000 or $10,000 could easily pay for itself.\u00a0 We have fewer options in this second population where the cost of care coordination should likely be held to a range of $1,000 to $2,000 per patient per year.<\/p>\n The “purple problem”<\/strong><\/p>\n In our view, identifying the best way to handle the second-most-expensive population is the middle of the problem.\u00a0 This set of folks is represented in purple below, and is the set of folks that are most likely to be transitioning to higher utilization.\u00a0 They are also probably the most challenging population to include in cost-effective care management services.<\/p>\n Process control systems<\/strong><\/p>\n Generally, the techniques to manage completion of the plan of care require technology.\u00a0 This is particularly true for the population represented in purple above.\u00a0 Just as we used predictive modeling tools to identify the patients that are targets for plans of care,\u00a0 process control tools (as reflected in EMRs, centralized clinical data aggregates, clinical data interchange, etc)\u00a0 are required to manage the cost of coordination of the plan of care.\u00a0 This is discussed in more detail under “Engage Patients”:<\/p>\n\n
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